Sexual Aversion Disorder is an often misunderstood diagnosis in the spectrum of sexual disorders. It is also the most recent of the disorders, first appearing in the DSM-III-R (1984). Although, technically, sexual aversion could be considered an anxiety disorder, it was not included in any of the earlier DSM editions as an example of a simple phobia. While it finally achieved legitimate status as a sexual disorder in 1984, it is often ignored or pushed to a secondary status within the field of sex therapy.
Given that the criteria for sexual aversion disorder overlap with both panic disorder and hypoactive sexual desire disorder, it is understandable that many clinicians, even experts in treating sexual disorders, remain somewhat unclear when to diagnose sexual aversion. For example, according to the DSM IV-TR criteria, sexual aversion does not require the physiologic responses that clinicians often associate with aversion.
Conditioned aversion is arguably best understood using Mowrer’s two-factor avoidance theory (Mowrer, 1947). He proposed that two separate learning processes were involved in avoidance conditioning: a conditioned emotional response (CER) and a conditioned avoidance response (CAR). The CER results from pairing a previously neutral or positive stimulus (sexual behavior) with a painful or traumatic event (and is therefore classically conditioned). When paired with discomfort, the sexual stimuli acquire the capacity to produce aversive emotional reactions (e.g., fear, anxiety, nausea, dizziness) in the absence of the original painful stimulation. The later response (CAR) is operantly conditioned in that avoidance of sexual stimulation eliminates or reduces the aversive response. Sexual aversion, from the two-factor avoidance perspective, can be conceptualized as a behavioral avoidance response.
While sexual aversion certainly can encompass these responses (e.g. nausea, revulsion, shortness of breath), aversion can also be expressed as simple avoidance of partnered sexual behavior and a panic response to engaging in partnered sexual activity.
The DSM-IV criteria for sexual aversion disorder are as follows: persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner; the disturbance causes marked distress or interpersonal difficulty; and the sexual dysfunction is not better accounted for by another Axis I disorder (except another sexual dysfunction). Sexual aversion disorder along with hypoactive sexual desire disorder make up the sexual desire disorders.
Aversion is a conditioned response that applies to behaviors beyond sexual. Outside the arena of sexual dysfunction, you may best recognize aversion as the conditioned response that develops in response to cancer chemotherapeutic agents. In this context, aversion implies more than phobic avoidance; aversion is characterized by nausea and vomiting. However, others writing on sexual aversion (.Katz and Jardine 1999), maintain that sexual aversion is equivalent to sexual phobia–the essential diagnostic feature is persistent fear and avoidance.
For those who prefer a more psychodynamic theoretical base, the persistence of avoidance behavior was articulated first by Freud (1936). Mowrer (1948) described the phenomenon as the neurotic paradox. The common observation that avoidance behavior is remarkably difficult to extinguish has been explained by the theory of conservation of anxiety. In essence, the argument is that individuals learn rapid avoidance over time, which prevents the elicitation of fear. Moreover, the theory goes, if fear is not elicited, it will not extinguish.
Women with aversion disorder typically report that sexual behavior became synonymous with aversion, but that their eventual avoidance of sexual behavior allowed their aversion response to remain relatively untriggered. Aversion was not elicited in situo because they learn to avoid sexual behavior so successfully. The theory of conservation of anxiety explains why sexual aversion rarely abates on its own, and, similarly, why it can be treatment-resistant. Crenshaw (1985) states that the sexual aversion syndrome is progressive and rarely reverses spontaneously. Patients are treatable in so far as they are willing to expose themselves rather unblinkingly to the anxiety accompanying sexual behavior. The following can help this exposure process along:
1) The clinician’s willingness and ability to conceptualize the patient’s sexual aversion in clear behavioral terms, emphasizing how aversion is acquired and maintained;
2) The patient’s ability to verbalize an understanding of aversion acquisition and maintenance, and, most importantly, to generate specific examples of the process of exposure;
3) The patient maintaining records of anxiety and aversion symptoms during the treatment process and referring to those records frequently during sessions. Patients will adhere to record-keeping instructions to the degree that clinicians make those records an integral part of the psychotherapy;
4) Emphasis on maintenance and generalization as the therapy draws to a close to address relapse issues.
Primary aversion is diagnosed when one’s first sexual experience, either directly or vicariously, is negative. Secondary aversion is diagnosed when the patient has had normal or pleasurable sexual development and experiences until a traumatic or painful experience, either direct or vicarious, negatively reconditions sexual interactions with a partner.
Despite improved clarity in the criterion for aversion, clinicians may continue to have difficulty with diagnosis and treatment. By virtue of the definition of aversion, most individuals with sexual aversion disorder tend to generalize avoidance behaviors to include even addressing the aversion in a therapy setting. Therefore, many individuals with sexual aversion will not present for treatment and those that do have often presented with a different chief complaint. It is up to the astute clinician to ferret out an aversion disorder as the primary problem. In addition, be sure that the diagnosis includes ruling out hypoactive sexual desire disorder since, as our first case demonstrates, aversion can exist in the context of intact desire.
San Diego Sexual Medicine is conveniently located on the spacious campus of Alvarado Hospital, a private, physician-owned hospital just ten miles from downtown San Diego, and is easily access by car or public transportation.